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FACILITATING SMOKING CESSATION

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FACILITATING SMOKING CESSATION

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    1. FACILITATING SMOKING CESSATION How to maximize your success rate in your office MAJ MICHAEL J. ROY, MD MPH Dept of Medicine, USUHS

    2. CURRENT STATUS 25% of Americans smoke 34% of soldiers smoke > 70% of smokers see an MD annually 70% want to, and have tried, to quit MDs advice is important motivator for attempting to quit

    3. DANGERS OF SMOKING Cancer Heart Disease Lung Disease Strokes & peripheral vascular disease Wrinkles & cataracts IUGR, prematurity, spontaneous Abs, SIDS

    4. TRENDS IN SMOKING Steady decline in males smoking No change for males with less than high school education Women with less than high school education continue to smoke in increasing numbers More black women stop when pregnant

    5. SOCIETAL PROGRESS Increased awareness of risks of passive smoke exposure, including for children Greater prohibitions on public use Efforts to regulate cigarettes as a drug Lawsuits vs. tobacco companies Tobacco companies admit wrongdoing

    6. ABCs of Smoking Cessation Ask & Advise Behavioral Issues Classes Drugs Encouragement Feedback, F/U, & Family Members Groups Hypnosis

    7. Ask & Advise: Ask about active and passive smoke exp. Advise strongly to quit; personalize advice Ascertain knowledge of risks/benefits Ask about interest in quitting Ask what prevented, or prevents, quitting Assist in quitting: develop a plan

    8. BEHAVIOR How many cigarettes/day? Early morning smoker? When do you smoke? (when stressed, after meals, after sex, on phone, in car...) What led to failure in past? Make replacement list, set quit date

    9. CLASSES Reported efficacy variable Peer support can be helpful Individualized element important Best used in conjunction with other efforts

    10. DRUGS Nicorette gum Transdermal Nicotine Nicotine spray & inhaler Clonidine: oral or transdermal Buproprion

    11. Nicorette gum Available without prescription Easily titratable Not tolerated by some patients Reported efficacy 10-40%; better as adjunct to other methods 4 mg better for heavier smokers Taper over up to 3 months

    12. Transdermal Nicotine Nicotrol, Nicoderm, & Habitrol OTC; Average price $25/week Reported efficacy 20-40% @ 6-12 months Apparent higher efficacy and acceptance, and requires less training in use, than gum Skin rash common, but most can continue Optimal treatment 8 weeks, including taper

    13. RECOMMENDED PATCH REGIMENS Prostep (24 hrs/day) 22 mg for 4 wks 11 mg for 4 wks Nicotrol (16 hrs/day) 15/10/5 mg for 4/2/2 best, but marketed OTC as one-step, 6 week easy course Nicoderm & Habitrol (24 hrs/day) 21 mg/day for 4 wks 14 mg/day for 2 wks 7 mg/day for 2 wks

    14. GUIDELINES FOR NICOTINE REPLACEMENT Avoid in pregnancy, unstable angina, immed. post-MI, & if serious arrhythmia Probably most important for heavy smokers Tailor use of gum but not patch Emphasize behavioral factors in addition

    15. Clonidine No convincing evidence of improvement in cessation rate, despite decrease in symptoms of withdrawal Consider in patients with coincident hypertension Hype may increase efficacy

    16. Buproprion SR (Zyban) Antidepressant, wk inhib of NE, DA, serot. Start @ 150 mg qd X 3d, then 150 BID Quit tobacco @ 1 week; continue med for 8 weeks after quitting 46% quit rate @ 10 wks, c/w 32% for patch 30% quit 12 mo quit rate, c/w 16% for patch May have greater effect combined w/patch

    17. Buproprion SR (Zyban) Contraindicated if seizure d/o, eating d/o; beware of factors predisposing to seizures such as alcoholism May be OK with other psychotropic meds, though prudent to start slowly and consider adjusting dose

    18. OTHER CONSIDERATIONS Encouragement/Feedback: high relapse rate Follow-up: remember to ask about success at subsequent visits Family Members: get them involved; also emphasize risk of passive smoke Groups: peer support for quitting Hypnosis: helpful for 10-15%

    19. Is it worth your time? MD attention increases quit rate Smoking assocd w/ high morb./mortality Cost effectiveness analyses indicate greater QALYs saved than with MMG, FOBT, F/S, lipid reduction, HTN screening--true for counseling, gum, patch If at first you dont succeed...

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